BiliaryPostoperative infectious complications caused by multidrug-resistant pathogens in patients undergoing major hepatectomy with extrahepatic bile duct resection
Introduction
Despite recent advances in diagnostic and surgical techniques and the refinement of perioperative management,1,2 hepatectomy with extrahepatic bile duct resection for perihilar malignancy remains challenging and is associated with high morbidity and mortality rates.3,4 In particular, postoperative infectious complication (POIC) is a major cause of morbidity and mortality.
Since the 1980s, various drug-resistant pathogens have emerged in the field of medicine.5, 6, 7, 8 Currently, pathogenic bacteria have increasingly gained resistance to multiple antimicrobial agents, and these multidrug-resistant (MDR) bacteria have become a significant public health threat7,8 In most patients with perihilar malignancy, preoperative biliary drainage is necessary, which leads to colonized/infected bile.9,10 We reported elsewhere10 that the incidence of preoperative biliary colonization/infection caused by MDR pathogens was 6.4% in patients undergoing surgery for perihilar cholangiocarcinoma and showed that major hepatectomy with extrahepatic bile duct resection can be performed with acceptable rates of morbidity and mortality, using appropriate antibiotic prophylaxis, even in patients with biliary colonization/infection caused by MDR pathogens. However, the impact of POIC caused by MDR pathogens (MDR-POIC) on the postoperative course of hepatectomy with extrahepatic bile duct resection has not been addressed. MDR-POIC after major surgery leads to a troublesome postoperative course because effective antimicrobial agents are limited.
The aim of the present study was to review the surgical outcome of patients undergoing major hepatectomy with extrahepatic bile duct resection with special attention to MDR-POIC and to clarify the incidence of and the risk factors for this difficult complication.
Section snippets
Patients
Medical records of consecutive patients (both male and female) who underwent combined liver and extrahepatic bile duct resection with intrahepatic cholangiojejunostomy at the First Department of Surgery, Nagoya University Hospital, Nagoya, Japan, between January 2006 and December 2017 were retrospectively reviewed with a focus on MDR-POIC. Patients who underwent hepatopancreatoduodenectomy were excluded.11 This study was approved by the Human Research Review Committee of Nagoya University
Study patients
During the 12-year study period, 620 consecutive patients, including 406 (65.5%) men and 214 women, underwent hepatectomy with extrahepatic bile duct resection. The median age was 67 years (22–89 years). Of these patients, 523 (84.4%) had cholangiocarcinoma, 48 (7.7%) had gallbladder cancer, and 49 (7.9%) had other diseases. A total of 518 (83.5%) patients had undergone preoperative biliary drainage, and 410 (66.1%) had colonized/infected bile before surgery. The types of hepatectomy performed
Discussion
In the present series of 620 patients who underwent major hepatectomy with extrahepatic bile duct resection, 219 (35.3%) patients developed POIC: 157 (25.3%) had non-MDR-POIC, and 62 (10.0%) had MDR-POIC. The latter patients, compared with the former patients, exhibited an unfavorable postoperative course and high mortality rate. These observations indicate that MDR-POIC has a substantial negative impact on short-term outcomes. Thus, preventing MDR-POIC is an urgent task to improve surgical
Funding/Support
No organizations funded our research.
Conflict of interest/Disclosure
None of the authors have received financial support or have direct or indirect personal relationships with people or organizations that could potentially and inappropriately influence their work and conclusions.
References (35)
- et al.
Preoperative biliary colonization/infection caused by multidrug-resistant (MDR) pathogens in patients undergoing major hepatectomy with extrahepatic bile duct resection
Surgery
(2018) - et al.
The effect of preoperative biliary drainage on infectious complications after hepatobiliary resection with cholangiojejunostomy
Surgery
(2013) - et al.
Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance
Clin Microbiol Infect
(2012) - et al.
Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS)
Surgery
(2011) - et al.
Postoperative pancreatic fistula: an international study group (ISGPF) definition
Surgery
(2005) - et al.
External biliary drainage following major liver resection for perihilar cholangiocarcinoma: impact on development of liver failure and biliary leakage
HPB (Oxford)
(2016) - et al.
Surgical technique and results of intrapancreatic bile duct resection for hilar malignancy (with video)
HPB (Oxford)
(2018) - et al.
Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections
Ann Surg
(2013) - et al.
Duration of antimicrobial prophylaxis in patients undergoing major hepatectomy with extrahepatic bile duct resection: a randomized controlled trial
Ann Surg
(2018) - et al.
Oncological superiority of hilar en bloc resection for the treatment of hilar cholangiocarcinoma
Ann Surg Oncol
(2012)
Clinical outcomes of left hepatic trisectionectomy for hepatobiliary malignancy
Br J Surg
New methods of control against postoperative methicillin-resistant Staphylococcus aureus infection
Surg Today
Methicillin-resistant Staphylococcus aureus (MRSA): Prevalence and epidemiology issues
Clin Lab Sci
Risk factors for organ/space surgical site infection after hepatectomy for hepatocellular carcinoma in 359 recent cases
J Hepatobiliary Pancreat Sci
Poor outcomes after hepatectomy in patients with ascites infected by methicillin-resistant staphylococci
J Hepatobiliary Pancreat Sci
Association of preoperative biliary stenting with increased postoperative infectious complications in proximal cholangiocarcinoma
Arch Surg
Hepatopancreatoduodenectomy for cholangiocarcinoma: a single-center review of 85 consecutive patients
Ann Surg
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The usefulness of preoperative bile cultures for hepatectomy with biliary reconstruction
2022, HeliyonCitation Excerpt :In addition, the cumulative number of patients with postoperative infectious complications increased linearly over time, with no obvious point of increase. In a previous study, the mortality of patients with postoperative infectious complications caused by MDR pathogens was higher than that in patients with postoperative infectious complications caused by non-MDR pathogens [21]. A randomized controlled trial that selected antimicrobial prophylaxis based on preoperative bile cultures reported that two-day administration of antimicrobial prophylaxis after surgery was sufficient for managing patients undergoing hepatectomy with extrahepatic bile duct resection [29].
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2022, Surgery (United States)Citation Excerpt :Some authors underlined the role of positive perioperative biliary cultures, which increase the rate of SIC.12,34 While Chen et al reported a rate of positive perioperative biliary cultures of 60% (n = 42), Sugawara et al counted 79.2% (n = 410) preoperative positive biliary cultures.3,35 In our study we collected the perioperative biliary cultures from 77 patients, among which 64 (83.1%) were positive and 13 (16.9%) were negative.
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